Air transportation safety recommendations

the Department of Transport require that pressurized SEIFR aircraft have sufficient supplemental oxygen to allow for an optimal glide profile during an engine-out let-down from the aircraft's maximum operating level until a cabin altitude of 13 000 feet is attained.

the Department of Transport require that SEIFR aircraft have a sufficient emergency electrical supply to power essential electrical systems following engine failure throughout the entirety of a descent, at optimal glide speed and configuration, from the aircraft's maximum operating level to ground level.

the Department of Transport require that the magnetic chip detecting system on PT-6-equipped single-engine aircraft be modified to provide a warning to the pilot of excessive ferrous material in the entire engine oil lubricating system.

the Department of Transport require that single-engine instrument flight rules SEIFR operators have in place an automatic system or an approved program that will monitor and record those engine parameters critical to engine performance and condition.

the Department of Transport review the equipment standard for SEIFR and include equipment technologies that would serve to further minimize the risks associated with SEIFR flight.

the Department of Transport improve the quality of pilot decision making in commercial air operations through appropriate training standards for crew members.

the Department of Transport ensure that all Canadian operators of the Beech King Air with the Aviadesign landing gear modification are advised of the circumstances of this accident and the safety actions taken, with the view toward implementing similar changes to prevent a future similar accident.

the Department of Transport notify the United States Federal Aviation Administration, in accordance with Annex 8, "Airworthiness of Aircraft," to the Convention on International Civil Aviation, about the circumstances of this accident and the safety actions taken, with the view toward wider application of the safety actions.

the Department of Transport issue an Airworthiness Directive to all Canadian owners and operators of Cessna 150 and 152 aircraft addressing a mandatory retrofit design change of the rudder horn stop bolt system to preclude over-travel and jamming of the rudder following a full rudder input.

the Department of Transport, in conjunction with the Federal Aviation Administration, take steps to have all operators of Cessna 150 and 152 aircraft notified about the circumstances and findings of this accident investigation and the need to restrict spin operations until airworthiness action is taken to prevent rudder jamming.

the Department of Transport take steps to ensure that operators and maintenance personnel are aware, in the interests of safety, of the importance of proper maintenance of aircraft journey logbooks and are aware of their responsibilities in this regard.

the National Transportation Safety Board review the circumstances and findings of this investigation and evaluate the need for mandatory airworthiness action by the Federal Aviation Administration.

the Department of Transport ensure that air operators store aircraft survival gear on aircraft in flame-resistant material and package emergency pyrotechnics and other highly flammable survival equipment at least to the standards required by International Air Transport Association IATA Dangerous Goods Regulations.

the Department of Transport ensure that helicopters used by private operators to transport passengers receive a standard of maintenance equivalent to that for fixed-wing aircraft for the same type of operation.

NAV CANADA commit, with a set date, to the installation and operation of an automated conflict prediction and alerting system at the nation's air traffic control facilities to reduce the risk of a midair collision.

appropriate regulatory authorities, in conjunction with the aviation community, review the adequacy of in-flight firefighting as a whole, to ensure that aircraft crews are provided with a system whose elements are complementary and optimized to provide the maximum probability of detecting and suppressing any in-flight fire.

appropriate regulatory authorities, together with the aviation community, review the methodology for establishing designated fire zones within the pressurized portion of the aircraft, with a view to providing improved detection and suppression capability.

appropriate regulatory authorities take action to ensure that industry standards reflect a philosophy that when odour/smoke from an unknown source appears in an aircraft, the most appropriate course of action is to prepare to land the aircraft expeditiously.

appropriate regulatory authorities ensure that emergency checklist procedures for the condition of odour/smoke of unknown origin be designed so as to be completed in a timeframe that will minimize the possibility of an in-flight fire being ignited or sustained.

appropriate regulatory authorities review current in-flight firefighting standards including procedures, training, equipment, and accessibility to spaces such as attic areas to ensure that aircraft crews are prepared to respond immediately, effectively and in a coordinated manner to any in flight fire.

the Department of Transport undertake a review of its safety oversight methodology, resources, and practices, particularly as they relate to smaller operators and those operators who fly in or into remote areas, to ensure that air operators and crews consistently operate within the safety regulations.

for the pressurized portion of an aircraft, flammability standards for material used in the manufacture of any aeronautical product be revised, based on realistic ignition scenarios, to prevent the use of any material that sustains or propagates fire.

a certification test regime be mandated that evaluates aircraft electrical wire failure characteristics under realistic operating conditions and against specified performance criteria, with the goal of mitigating the risk of ignition.

as a prerequisite to certification, all aircraft systems in the pressurized portion of an aircraft, including their sub-systems, components, and connections, be evaluated to ensure that those systems whose failure could exacerbate a fire in progress are designed to mitigate the risk of fire-induced failures.

the Bell 214B and Bell 205 flight manuals be modified to provide information regarding the inaccuracy of fuel quantity indications, thereby allowing pilots to make informed decisions in the event of a loss of fuel boost pump pressure.

the Department of Transport expedite the approach ban regulations prohibiting pilots from conducting approaches in visibility conditions that are not adequate for the approach to be conducted safely.

the Department of Transport take immediate action to implement regulations restricting pilots from conducting approaches where the ceiling does not provide an adequate safety margin for the approach or landing.

Transport Canada, the United States Federal Aviation Administration, and Fairchild explore options for SA226 and SA227 aircraft to be equipped with a brake pressure warning indicator for each main wheel brake system.

the Department of Transport take action to reduce the short term risk and eliminate the long term risk of heater ribbon installation failures starting fires, and coordinate and encourage a similar response from other appropriate regulatory authorities.

the Department of Transport take action to reduce the short term risk and eliminate the long term risk of contaminated insulation materials and debris propagating fires, and coordinate and encourage a similar response from other appropriate regulatory authorities.

regulatory authorities quantify and mitigate the risks associated with in service thermal acoustic insulation materials that have failed the Radiant Panel Test.

Regulatory authorities develop a test regime that will effectively prevent the certification of any thermal acoustic insulation materials that, based on realistic ignition scenarios, would sustain or propagate a fire.

regulatory authorities take action to ensure the accurate and consistent interpretation of the regulations governing material flammability requirements for aircraft materials so as to prevent the use of any material with inappropriate flammability characteristics.

regulatory authorities require that every system installed through the STC process undergo a level of quantitative analysis to ensure that it is properly integrated with aircraft type-certified procedures, such as emergency load-shedding.

regulatory authorities establish the requirements and industry standard for circuit breaker resetting.

regulatory authorities, in concert with the aviation industry, take measures to enhance the quality and intelligibility of CVR recordings.

regulatory authorities require, for all aircraft manufactured after 1 January 2007 which require an FDR, that in addition to the existing minimum mandatory parameter lists for FDRs, all optional flight data collected for non-mandatory programs such as FOQA/FDM, be recorded on the FDR.

regulatory authorities develop harmonized requirements to fit aircraft with image recording systems that would include imaging within the cockpit.

regulatory authorities harmonize international rules and processes for the protection of cockpit voice and image recordings used for safety investigations.

the Department of Transport require that actual passenger weights be used for aircraft involved in commercial or air taxi operations with a capacity of nine passengers or fewer.

the Department of Transport re-evaluate the standard weights for passengers and carry-on baggage and adjust them for all aircraft to reflect the current realities.

the Direction Générale de l'Aviation Civile and the Federal Aviation Administration issue airworthiness directives to require the implementation of all CFM56-5 series jet engine service bulletins whose purpose is to incorporate software updates designed to ensure that, in the event of a permanent magnet alternator failure, the electronic control unit will revert to aircraft power.

the Department of Transport ensure the continued airworthiness of Canadian-registered aircraft fitted with the CFM56-5 series engine by developing an appropriate safety assurance strategy to make certain that, in the event of a permanent magnet alternator failure, the electronic control unit will revert to aircraft power.

the Department of Transport take action to restrict the dispatch of Canadian Cessna 208, 208A, and 208B aircraft into forecast icing meteorological conditions exceeding "light," and prohibit the continued operation in these conditions, until the airworthiness of the aircraft to operate in such conditions is demonstrated.

the Department of Transport require that Canadian Cessna 208 operators maintain a minimum operating airspeed of 120 knots during icing conditions and exit icing conditions as soon as performance degradations prevent the aircraft from maintaining 120 knots.

the Federal Aviation Administration take action to revise the certification of Cessna 208, 208A, and 208B aircraft to prohibit flight into forecast or in actual icing meteorological conditions exceeding "light," until the airworthiness of the aircraft to operate in such conditions is demonstrated.

the Federal Aviation Administration require that Cessna 208 operators maintain a minimum operating airspeed of 120 knots during icing conditions and exit icing conditions as soon as performance degradations prevent the aircraft from maintaining 120 knots.

the Department of Transport, in coordination with other involved regulatory authorities and industry, urgently develop and implement an inspection program that will allow early and consistent detection of damage to the rudder assembly of aircraft equipped with part number A55471500 series rudders.

the European Aviation Safety Agency, in coordination with other involved regulatory authorities and industry, urgently develop and implement an inspection program that will allow early and consistent detection of damage to the rudder assembly of aircraft equipped with part number A55471500 series rudders.

the Department of Transport, in conjunction with the International Civil Aviation Organization, the Federal Aviation Administration, the European Aviation Safety Agency, and other regulatory organizations, establish a requirement for transport category aircraft to be equipped with a take-off performance monitoring system that would provide flight crews with an accurate and timely indication of inadequate take-off performance.

Transport Canada, together with the Federal Aviation Administration and other foreign regulators, revise the cost-benefit analysis for Notice of Proposed Rule Making 85-7A using Canadian post-impact fire statistics and current value of statistical life rates, and with consideration to the newest advances in post-impact fire prevention technology.

to reduce the number of post-impact fires in impact-survivable accidents involving new production aeroplanes weighing less than 5700 kg, Transport Canada, the Federal Aviation Administration, and other foreign regulators include in new aeroplane type design standards:methods to reduce the risk of hot items becoming ignition sources; technology designed to inert the battery and electrical systems at impact to eliminate high-temperature electrical arcing as a potential ignition source; requirements for protective or sacrificial insulating materials in locations that are vulnerable to friction heating and sparking during accidents to eliminate friction sparking as a potential ignition source; requirements for fuel system crashworthiness; requirements for fuel tanks to be located as far as possible from the occupied areas of the aircraft and for fuel lines to be routed outside the occupied areas of the aircraft to increase the distance between the occupants and the fuel; and improved standards for exits, restraint systems, and seats to enhance survivability and opportunities for occupant escape.

to reduce the number of post-impact fires in impact-survivable accidents involving existing production aircraft weighing less than 5700 kg, Transport Canada, the Federal Aviation Administration, and other foreign regulators conduct risk assessments to determine the feasibility of retrofitting aircraft with the following: selected technology to eliminate hot items as a potential ignition source; technology designed to inert the battery and electrical systems at impact to eliminate high-temperature electrical arcing as a potential ignition source; protective or sacrificial insulating materials in locations that are vulnerable to friction heating and sparking during accidents to eliminate friction sparking as a potential ignition source; and selected fuel system crashworthiness components that retain fuel.

the Department of Transport establish clear standards limiting approaches and landings in convective weather for all air transport operators at Canadian airports.

France's Direction Générale de l'Aviation Civile and other civil aviation authorities establish clear standards limiting approaches and landings in convective weather.

the Department of Transport mandate training for all pilots involved in Canadian air transport operations to better enable them to make landing decisions in deteriorating weather.

France's Direction Générale de l'Aviation Civile and other civil aviation authorities mandate training for air transport pilots to better enable them to make landing decisions in deteriorating weather.

the Department of Transport and other civil aviation authorities require crews to establish the margin of error between landing distance available and landing distance required before conducting an approach into deteriorating weather.

the Department of Transport require all Code 4 runways to have a 300 m runway end safety area RESA or a means of stopping aircraft that provides an equivalent level of safety.

the Department of Transport require that passenger safety briefings include clear direction to leave all carry-on baggage behind during an evacuation.

the Department of Transport take into account all propulsion system failures when assessing the safety of single-engine commercial operations.

the European Aviation Safety Agency, in coordination with other involved regulatory authorities and industry, ensure that the AS 350 helicopter hydraulic cut-off switch is capable of handling the inductive electrical load of the circuit.

the Department of Transport ensure that passenger carrying commercial balloon operations provide a level of safety equivalent to that established for other aircraft of equal passenger carrying capacity.

the Department of Transport ensure that balloons carrying fare-paying passengers have an emergency fuel shut-off.

the Department of Transport, in coordination with NAV CANADA, take steps to substantially reduce the risk of collision between visual flight rules aircraft operating in Class E airspace surrounding the Toronto/Lester B. Pearson International Airport.

the Department of Transport require air carriers to incorporate bounced landing recovery techniques in their flight manuals and to teach these techniques during initial and recurrent training.

CARs subpart 703 air taxi and CARs subpart 704 commuter pilots.

the Department of Transport ensure that eye-to-wheel height information is readily available to pilots of aircraft exceeding 12 500 pounds.

the Department of Transport require training on visual glide slope indicator VGSI systems so pilots can determine if the system in use is appropriate for their aircraft.

the Canadian Business Aviation Association set safety management system implementation milestones for its certificate holders.

the Department of Transport ensure that the Canadian Business Aviation Association implement an effective quality assurance program for auditing certificate holders.

the Federal Aviation Administration, Transport Canada and the European Aviation Safety Agency remove the "extremely remote" provision from the rule requiring 30 minutes of safe operation following the loss of main gearbox lubricant for all newly constructed Category A transport helicopters and, after a phase-in period, for all existing ones.

the Federal Aviation Administration assess the adequacy of the 30 minute main gearbox run dry requirement for Category A transport helicopters.

Transport Canada prohibit commercial operation of Category A transport helicopters over water when the sea state will not permit safe ditching and successful evacuation.

Transport Canada require that supplemental underwater breathing apparatus be mandatory for all occupants of helicopters involved in overwater flights who are required to wear a PTSS.

the Department of Transport require that all new and existing commercial seaplanes be fitted with regular and emergency exits that allow rapid egress following a survivable collision with water.

the Department of Transport require that occupants of commercial seaplanes wear a device that provides personal flotation following emergency egress.

the Department of Transport require that the design and depiction of the non-precision approach charts incorporate the optimum path to be flown.

the Department of Transport require the use of the stabilized constant descent angle approach technique in the conduct of non-precision approaches by Canadian operators.

the Department of Transport work with industry to remove obstacles to and develop recommended practices for the implementation of flight data monitoring and the installation of lightweight flight recording systems by commercial operators not currently required to carry these systems.

the Department of Transport require underwater egress training for all flight crews engaged in commercial seaplane operations.

the Department of Transport require that all seaplanes in commercial service certificated for 9 or fewer passengers be fitted with seatbelts that include shoulder harnesses on all passenger seats.

Transport Canada require CARs Subpart 705 operators to monitor and reduce the incidence of unstable approaches that continue to a landing.

the Department of Transport require commercial air carriers to collect and report, on a routine basis, the number of infants (under 2 years old), including lap-held, and young children (2 to 12 years old) travelling.

the Department of Transport work with industry to develop age- and size-appropriate child restraint systems for infants and young children travelling on commercial aircraft, and mandate their use to provide an equivalent level of safety compared to adults.

the Department of Transport require all Canadian-registered aircraft and foreign aircraft operating in Canada that require installation of an emergency locator transmitter (ELT) to be equipped with a 406 MHz ELT in accordance with International Civil Aviation Organization Standards.

the International Civil Aviation Organization establish rigorous emergency locator transmitter (ELT) system crash survivability standards that reduce the likelihood that an ELT system will be rendered inoperative as a result of impact forces sustained during an aviation occurrence.

the Radio Technical Commission for Aeronautics establish rigorous emergency locator transmitter (ELT) system crash survivability specifications that reduce the likelihood that an ELT system will be rendered inoperative as a result of impact forces sustained during an aviation occurrence.

the European Organisation for Civil Aviation Equipment establish rigorous emergency locator transmitter (ELT) system crash survivability specifications that reduce the likelihood that an ELT system will be rendered inoperative as a result of impact forces sustained during an aviation occurrence.

the Department of Transport establish rigorous emergency locator transmitter (ELT) system crash survivability requirements that reduce the likelihood that an ELT system will be rendered inoperative as a result of impact forces sustained during an aviation occurrence.

Cospas-Sarsat amend the 406-megahertz emergency locator transmitter first-burst delay specifications to the lowest possible timeframe to increase the likelihood that a distress signal will be transmitted and received by search-and-rescue agencies following an occurrence.

the Department of Transport prohibit the use of hook-and-loop fasteners as a means of securing an emergency locator transmitter to an airframe.

the Department of Transport amend the regulations to clearly define the visual references (including lighting considerations and/or alternate means) required to reduce the risks associated with night visual flight rules flight.

the Department of Transport establish instrument currency requirements that ensure instrument flying proficiency is maintained by instrument-rated pilots, who may operate in conditions requiring instrument proficiency.

the Department of Transport require terrain awareness and warning systems for commercial helicopters that operate at night or in instrument meteorological conditions.

the Department of Transport establish pilot proficiency check standards that distinguish between, and assess the competencies required to perform, the differing operational duties and responsibilities of pilot-in-command versus second-in-command.

the Department of Transport require all commercial aviation operators in Canada to implement a formal safety management system.

the Department of Transport conduct regular SMS assessments to evaluate the capability of operators to effectively manage safety.

the Department of Transport enhance its oversight policies, procedures and training to ensure the frequency and focus of surveillance, as well as post-surveillance oversight activities, including enforcement, are commensurate with the capability of the operator to effectively manage risk.

the Department of Transport require all commercially operated DHC-2 aircraft in Canada to be equipped with a stall warning system.

the Department of Transport, in collaboration with the Canadian aviation industry and employee representatives, develop and implement requirements for a comprehensive substance abuse program, including drug and alcohol testing, to reduce the risk of impairment of persons while engaged in safety‑sensitive functions. These requirements should consider and balance the need to incorporate human rights principles in the Canadian Human Rights Act with the responsibility to protect public safety.

the Department of Transport require the mandatory installation of lightweight flight recording systems by commercial operators and private operators not currently required to carry these systems.

the Department of Transport collaborate with air operators and airport authorities to identify locations where there is inadequate de-icing and anti-icing equipment and take urgent action to ensure that the proper equipment is available to reduce the likelihood of aircraft taking off with contaminated critical surfaces.

subsection 602.11(2) and reduce the likelihood of aircraft taking off with contaminated critical surfaces.

NAV CANADA amend its phraseology guidance so that safety-critical transmissions issued to address recognized conflicts, such as those instructing aircraft to abort takeoff or pull up and go around, are sufficiently compelling to attract the flight crew's attention, particularly during periods of high workload.

the Department of Transport work with operators to amend standard operating procedures so that post-landing checks are sequenced only after landing aircraft are clear of both active runways when closely spaced parallel runway operations are in effect, rather than the current common practice of sequencing the checks once landing aircraft are clear of the landing surface.

the United States Federal Aviation Administration work with operators to amend standard operating procedures so that post-landing checks are sequenced only after landing aircraft are clear of both active runways when closely spaced parallel runway operations are in effect, rather than the current common practice of sequencing the checks once landing aircraft are clear of the landing surface.

the Greater Toronto Airports Authority make physical changes to the taxiway layout to address the risk of incursions between the parallel runways and, until these changes can be made, make further improvements to increase the conspicuity of the runway holding positions.

to remove any ambiguity associated with the definition of “safety belt.”

the Department of Transport collaborate with industry associations to develop strategies, education products, and tools to help air-taxi operators and their clients eliminate the acceptance of unsafe practices.

Industry associations (e.g., ATAC, HAC, AQTA, FOA, NATA) promote proactive safety management processes and safety culture with air-taxi operators to address the safety deficiencies identified in this safety issue investigation through training and sharing of best practices, tools, and safety data specific to air-taxi operations.

the Department of Transport review the gaps identified in this safety issue investigation regarding Subpart 703 of the Canadian Aviation Regulations and  associated standards, and update the relevant regulations and standards.

subpart and aircraft type, and that the Department of Transport publish those data.

the Department of Transport review and simplify operating minima for approaches and landings at Canadian aerodromes.

the Department of Transport introduce a mechanism to stop approaches and landings that are actually banned.

NAV CANADA make available, in a timely manner, graphic depictions of closures and other significant changes related to aerodrome or runway operations to accompany the associated NOTAMs, so that the information communicated on these hazards is more easily understood.

to ensure it contains the most effective screening tools for assessing medical conditions such as cardiovascular health issues.

the Department of Transport require commercial helicopter operators to ensure pilots possess the skills necessary to recover from inadvertent flight into instrument meteorological conditions.

the Department of Transport require commercial helicopter operators to implement technology that will assist pilots with the avoidance of, and recovery from, inadvertent flight into instrument meteorological conditions.

the Department of Transport require operators conducting single-pilot operations under Subpart 604 and Part VII of the Canadian Aviation Regulations to develop standard operating procedures based on corporate knowledge and industry best practices to support pilot decision making.

the Department of Transport enhance the requirements for helicopter operators that conduct reduced-visibility operations in uncontrolled airspace to ensure that pilots have an acceptable level of protection against inadvertent flight into instrument meteorological conditions accidents.

the Department of Transport revise conditions for the issue and maintenance of a night endorsement by:

the Department of Transport require verification of proficiency in basic instrument flying skills for commercially-employed helicopter pilots during annual pilot proficiency flight checks.

The Department of Transport require all helicopters engaged in commercial passenger carrying operations be equipped with radar altimeters.

the Department of Transport require all commercially-operated helicopters to be equipped with appropriate instrumentation for the conduct of basic instrument flying.

the Department of Transport devise and implement a means of regularly evaluating the practical decision-making skills of commercially-employed pilots engaged in small air carrier operations.

the Department of Transport locate automated weather measuring devices in support of VFR operations in the areas of highest risk in mountainous terrain.

the Department of Transport examine the policy for the contracting of manned weather observation services with a view to expanding the service in remote locations of highest risk.

the Department of Transport validate its approval process for FDRs to ensure that current procedures are adequate to meet the ANO and Engineering and Inspection Manual requirements.

the Department of Transport ensure that the appropriate FDR correlation data is available for all installed FDRs and that companies have adequate maintenance plans and procedures for ensuring the continued serviceability of these FDRs

the Department of Transport sponsor modifications to the existing design of the emergency exit handle access system on Bell models 204, 205, 212, and 214 helicopters that are currently equipped with emergency exit handle covers, to ensure that the emergency exit handles can consistently and easily be accessed.

the Department of Transport immediately require Canadian operators of Bell models 205Al and 212 helicopters engaged in “heli-skiing” or “heli-hiking” operations to install Bell's optional push-out window emergency exits.

the Department of Transport expedite legislation for upgrading the flight recorder requirements for Canadian-registered aircraft.

the Department of Transport ensure that the HS 748 Flight Manual and Crew Manual are amended to include appropriate warnings regarding the possibility of aileron aerodynamic overbalance and procedures to be followed should it be encountered.

the Department of Transport evaluate its review process concerning Letters-to-Operators to ensure the continuing airworthiness and safe operation of Canadian registered aircraft.

the Department of Transport clarify the operator compliance requirements with respect to Letters-to-Operators.

the Department of Transport change the VFR weather minima required for landing fixed wing aircraft in uncontrolled airspace so that the VFR minima provide a level of safety at least equivalent to that provided by IFR circling minima.

the Department of Transport reconsider the feasibility and practicality of including a first aid kit specifically equipped for post accident survival in the aircraft survival kit required by Air Navigation Order (ANO) Series V, No. 12.

the Department of Transport provide guidance for air carriers to assist in the effective pairing of flight crews.

the Department of Transport validate its current procedures for checking that air carriers provide the required multi-engine night training.

the Department of Transport coordinate the development and implementation of airworthiness standards and operational limitations for helicopter slinging equipment.

the Department of Transport provide operational supervisors with general criteria and practical training for making timely decisions on the staffing, opening, and closing of sectors.

the Department of Transport consider including mandatory dual flight instruction in glassy water, cross-wind and rough water conditions in the alternate seaplane endorsement flight training syllabi.

the Department of Transport require an endorsement to the Commercial and Airline Transport licences for seaplane instruction which would entitle the holder to provide alternate seaplane flight and ground school training to pilots.

the Department of Transport implement a specific knowledge and skill test for the alternate seaplane endorsement

the Department of Transport require that all seaplane endorsements be recommended by a seaplane instructor who has been designated as seaplane flight examiner.

the Department of Transport establish a mandatory periodic flight review on seaplanes for the maintenance of the operating privileges of a seaplane endorsement.

the Department of Transport streamline its processes to facilitate the timely Canadian implementation of updated flight recorder requirements.

the Department of Transport require that all occupants of seaplanes wear a personal flotation device during the standing, taxiing, take-off, and approach and landing phases of flight.

the Department of Transport investigate options for imposing strong sanctions on owners and operators who flagrantly disregard the basic tenets of safety in seaplane operations, and make public its findings within one year of the receipt of these recommendations.

the Department of Transport promulgate guidelines regarding the use of "non-approved" material contained in aircraft flight manuals, including related operational information issued by aircraft manufacturers.

the Bombardier Corporation amend the Twin Otter (DHC-6) Aircraft Flight Manual (PSM 1-63-1A) and Supplementary Operating Data Manual (PSM 1-63-1) to include appropriate warnings regarding any safety limitations associated with the operation of the aircraft in the "maximum performance" STOL configuration.

the Department of Transport, in consultation with the aviation industry, implement a special safety campaign to inform the helicopter community of the inherent risks involved in the ad hoc practice of penetrating cloud/fog in VFR operations, particularly in mountainous regions.

the Department of Transport place increased emphasis on achieving compliance with respect to VFR weather limits for commercial helicopter operations.

the Department of Transport, in conjunction with industry, explore measures to counter attitudes that "pressing-the-weather" is an acceptable practice in commercial VFR helicopter operations.

the Department of Transport re-evaluate research regarding protective breathing equipment (PBE) for passengers with a view to determining the feasibility of the carriage of appropriate protective breathing equipment, on a voluntary basis.

the Department of Transport, in concert with industry, re-evaluate the performance of escape slides on all large passenger-carrying aircraft registered in Canada, to confirm that they can be functionally deployed in accordance with the criteria of the Airworthiness Standard.

the Department of Transport encourage carriers to include sufficient detail in their pre-landing briefings to prepare passengers for an unplanned emergency evacuation.

the Department of Transport expedite the implementation of approved GPS standards and procedures for use in Canadian airspace.

the Department of Transport require the installation of an independently powered standby attitude indicator on all turbine-powered, IFR- approved commuter and airline aircraft capable of carrying 10 or more passengers.

the Department of Transport require the installation of GPWS on all turbine-powered, IFR-approved, commuter and airline aircraft capable of carrying 10 or more passengers.

the Department of Transport establish guidelines for crew resource management (CRM) and decision-making training for all operators and aircrew involved in commercial aviation.

the Department of Transport establish procedures for evaluating crew resource management (CRM) and pilot decision-making (PDM) skills on a recurrent basis for all aircrew involved in commercial aviation.

the Department: of Transport conduct a special one-time audit to confirm that commercial pilots involved in night, multi-engine operations are receiving the required night training.

the Department of Transport evaluate the effectiveness of its current practices for dealing with those operators who are not providing mandatory training for pilots.

the Department of Transport revise the guidelines for grouping aircraft for PPCs to take into account the susceptibility to transfer errors by aircrew.

the Department of Transport require that the operators of state aircraft be subject to regulatory overview, as practicable, equivalent to that of similar commercial operations.

the Department of Transport expedite the development and implementation of safe separation procedures for the use of GPS in navigation.

the Department of Transport, using accepted risk management methodologies, create carrier-specific requirements for the carriage of first aid kits, survival equipment, and upgraded ELTs on all commercial aircraft.

the Department of Transport require that pilots involved in air-taxi and commuter operations receive specialized training, including skills development, in making prudent decisions under deteriorating operational conditions.

the Department of Transport ensure that flight crews operating high bypass ratio engines can correctly identify and respond to compressor stalls or surges.

the Department of Transport require all air carriers operating air ambulance services in the course of their business to provide the equipment, procedures, and crew training necessary to ensure a level of safety for patients consistent with that provided by commercial air services to fare-paying passengers.

as of 01 January 2003, any CVR installed on an aircraft as a condition of that aircraft receiving an original certificate of airworthiness be required to have a recording capacity of at least two hours.

as of 01 January 2005, all aircraft that require both an FDR and a CVR be required to be fitted with a CVR having a recording capacity of at least two hours.

as of 01 January 2005, for all aircraft equipped with CVRs having a recording capacity of at least two hours, a dedicated independent power supply be required to be installed adjacent or integral to the CVR, to power the CVR and the cockpit area microphone for a period of 10 minutes whenever normal aircraft power sources to the CVR are interrupted.

aircraft required to have two flight recorders be required to have those recorders powered from separate generator buses.

the Department of Transport reassess Category I approach and landing criteria re-aligning weather minima with operating requirements to ensure a level of safety consistent with Category II criteria.

regulatory authorities confirm that sufficient action is being taken, on an urgent basis, to reduce or eliminate the risk associated with the use of metallized PET-covered insulation blankets in aircraft.

on an urgent basis, regulatory authorities validate all thermal acoustical insulation materials in use, or intended for use, in applicable aircraft, against test criteria that are more rigorous than those in Appendix F of FAR 25.853, and similar regulations, and that are representative of actual in-service system performance.